Automatic Bank Withdrawal Authorization Form

Last Street City State Zip Bank Name: Account Owner: Account Type: (Checking / Savings Only) Bank Routing Number: Account Number: I authorize John Hancock Life & Health Insurance Company/John Hancock Life Insurance Company ( ) to initiate Automatic bank withdrawals from my account in order to effect payment of my premium. Also, I authorize my bank to charge such account for such withdrawals. I understand that I will not receive any bills or notices of Withdrawal from John Hancock. I also understand that if any Withdrawal is not honored by my bank for any reason, I am responsible to pay my premium or my insurance coverage will be terminated.

terminated. This authorization will remain in effect until I, my bank or John Hancock terminates it by giving a thirty (30) day written termination notice to the others. Automatic Bank Withdrawal Authorization Form . Use this form to authorize withdrawals from your checking/savings account to pay your insurance premium. Introduction

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